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Guidelines for the Management of Diabetes

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Guidelines for the Management of Diabetes A Whittington Hospital Clinical Management Guideline Guidelines for the Management of Diabetes Date: April 2005 Review Date: April 2007 Author: Dr Maria Barnard Speciality : Lead Consultant in Diabetes Directorate: Medicine The Whittington Hospital Edition 1 • These guidelines are available on our website: www.whittington.nhs.uk/diabetes • They are intended to help teams manage diabetes. • They were originally written as a joint initiative between the specialist hospital diabetes team and primary care providers in Islington and West Haringey, with targets and care aligned between The Whittington Hospital and University College London Hospital. • These guidelines focus on the management of type 2 diabetes. In addition, there are sections relevant to the management of type 1 diabetes and local initiatives. • The original Whittington Hospital and Islington PCT guidelines were reviewed by the President of the Royal College of Physicians: “Thank you again for letting me see your very good guidelines.” Professor Sir George Alberti, PRCP (March 2001) Comments from all primary and secondary care providers are welcome. These guidelines will be updated regularly and your comments will be taken into account. Please address comments and/or enquiries to: Dr Maria Barnard, Lead Consultant in Diabetes Diabetes Office The Jenner Building The Whittington Hospital Highgate Hill London N19 5NF Tel: 020 7288 5218 Fax: 020 7288 5052 e-mail: [email protected] 2 CONTRIBUTORS AND EDITORIAL BOARD This edition of the guidelines has been updated and edited by Dr Maria Barnard, April 2005 EDITORIAL BOARD OF FIRST EDITION OF WHITTINGTON HOSPITAL & ISLINGTON PCT GUIDELINES (March 2001) Primary Care Providers: Dr Maggie Tatham, GP Goodinge Health Centre Dr Jonathan Riddell, GP Highgate Group Practice Dr Nick Brand, GP Highbury New Park Cathy Jenkins, Practice Nurse Parkhurst Road Practice (now Diabetes Specialist Nurse at The Whittington Hospital) The Whittington Hospital Diabetes Team: Dr Maria Barnard Lead Consultant Physician in Diabetes Jill Lankester Senior Diabetes Specialist Nurse Shirley Burnett Optometry Eye Screening Co-ordinator Maria Christofi Prompted Care Co-ordinator Janice Mavroskoufis Senior Dietitian Angela Ryle Senior Dietitian Jennifer Buchanan Senior Podiatrist DESKTOP EDITING Dr Robert Lee Dr Maria Barnard Copyright Department of Diabetes, The Whittington Hospital NHS Trust and the North & Central London Group, 2001 3 CONTENTS Summary Guidelines For The Management Of Diabetes 2005: Summary 8 Management Targets For People With Diabetes 10 Whittington Trust Diabetes Out-Patient Services 11 1. Outpatient diabetes clinic times 11 2. Whittington Trust diabetes related staff 12 Education & Service Initiatives Available At The Whittington Hospital Diabetes Department 13 Chapter 1: Screening, Diagnosis & Initial Action 14 1. Screening and diagnosis 15 2. Positive urinalysis for glucose 17 3. Diabetes diagnosed – initial action and referral 18 A) Does the patient need insulin? 18 B) All others – start management in General Practice 18 C) All new patients – initial action points 18 4. Criteria for specialist referral 19 1) Urgent referral 19 2) Routine referral 19 3) Who should patients be referred to? 19 4) Referral letter to the hospital 19 Chapter 2: Education In Type 2 Diabetes 20 1. Type 2 diabetes group education sessions 21 2. Continuing diabetes education in general practice 22 3. Education of people with type 2 diabetes – a checklist 23 Chapter 3: Dietary Advice 24 1. Dietary advice for people with diabetes 25 2. First aid dietary advice for the patient with diabetes 27 3. How to get dietary advice for people with diabetes 28 4. Referral form to dietitian – Islington PCT 29 5. Nutrition and Dietetics clinics in Islington 30 6. Primary care dietitians in Enfield & Haringey 31 7. Accessing dietetic advice in primary care in Haringey 32 Chapter 4: Weight Management 33 1. Weight management in people with diabetes 34 2. Guidance for use of orlistat in diabetes 35 3. Guidance for use of sibutramine in diabetes 36 4 Chapter 5: Physical Activity 37 1. Physical activity and diabetes 38 1) Why exercise; local exercise programmes; starting up; frequency and intensity 38 2) Time; type; exclusion criteria; how to recruit; resources and information 39 3) Hypoglycaemia; hyperglycaemia 40 2. Exercise recommendations for specific complications in diabetes 41 3. How to prescribe increased physical activity and exercise 42 4. Haringey PCT ‘Fit for Life’ poster 43 5. Haringey PCT ‘Fit for Life’ recruitment form 44 Chapter 6: Home Monitoring 46 1. Self monitoring in diabetes care 47 2. Urine glucose testing 47 3. Blood glucose monitoring 47 4. Teaching blood glucose monitoring 48 5. Frequency and timing 49 6. Urine ketone testing 50 7. Guidelines for monitoring housebound patients with diabetes 51 1) Housebound patients controlled with diet or tablets 51 2) Housebound patients controlled with insulin 52 Chapter 7: Treatment Of Type 2 Diabetes & Oral Antidiabetic Drugs 53 1. Treatment scheme for overweight subjects with type 2 diabetes (BMI > 25) 54 2. Treatment scheme for normal weight subjects with type 2 diabetes (BMI ≤ 25) 55 3. Oral antidiabetic drugs 56 4. Oral antidiabetic drugs – summary 60 Chapter 8: Insulin 61 1. Commonly used insulins 62 2. Common insulin regimens 63 1) Type 1 diabetes mellitus 63 2) Type 2 diabetes mellitus 64 3) Elderly patients with diabetes 64 4) Using human vs. animal insulin 64 Chapter 9: Diabetic Emergencies 65 Management of the sick patient with diabetes 66 A) Sick-day rules 66 1) Patients with type 1 diabetes 67 Does the patient need admitting to hospital? – type 1 diabetes 67 Managing the sick patient at home – type 1 diabetes 68 2) Patients with type 2 diabetes 69 Does the patient need admitting to hospital? – type 2 diabetes 69 Managing the sick patient at home – type 2 diabetes 70 B) Hypoglycaemia 72 5 Chapter 10: Diabetes Review Formats & Continuing Care 75 1. Type 2 diabetes – initial assessment 76 2. Type 2 diabetes – routine review 77 3. Type 2 diabetes – annual review 78 4. Arrangements for shared care 80 5. Prompted community diabetes care for patients with type 2 diabetes 81 Chapter 11: Cardiovascular Risk And Aspirin In Diabetes 84 1. Reducing coronary heart disease in diabetes 85 2. Aspirin therapy in diabetes 86 Chapter 12: Hypertension 87 1. Blood pressure 88 2. Measuring blood pressure 88 3. Targets in patients with diabetes 88 4. 24 hour ambulatory blood pressure monitoring 89 5. Hypertension treatment 89 6. Lifestyle measures 90 7. Selecting drug treatment for hypertension in diabetes 90 8. Guidelines for selecting drug treatment - summary 91 Chapter 13: Lipids 92 1. Lipids in diabetes 93 2. Targets for lipids in diabetes 94 3. Management of hyperlipidaemia in patients with diabetes 95 4. Lipid regulating drugs 96 Chapter 14: Retinal Screening 100 1. Camden, Islington and West Haringey retinal screening programme 101 2. Retinal screening protocol – follow up and referral criteria 102 Chapter 15: Footcare In Diabetes 103 1. Diabetic foot disease 104 2. Prevention of diabetic foot disease 104 3. When to refer to hospital 105 4. The diabetic foot assessment – summary 106 5. The diabetic foot assessment 107 6. Risk categories 110 7. Footcare advice for people with diabetes 111 8. Diabetic neuropathy 112 9. Management of diabetic peripheral neuropathy 113 6 Chapter 16: Kidney Disease: Screening & Management 114 1. Microalbuminuria / proteinuria screening 115 2. Clinic referral criteria 115 3. Screening protocol 116 4. Screening using timed collections 117 5. Definitions 117 6. Targets 117 7. Estimated glomerular filtration rate (calculated creatinine clearance) 118 8. Timed collections – organising and instructions 119 9. 24 hour urine collection – instructions for patients 120 Chapter 17: Sexual Health & Women’s Health 121 1. Erectile dysfunction 122 2. Hormone replacement therapy in diabetes 124 3. Contraception in diabetes 126 4. Pre-conception care in women with diabetes 127 5. Screening for gestational diabetes 128 6. After gestational diabetes – a guide for patients 129 Chapter 18: Travel & Diabetes 130 1. Travelling with your diabetes – patient on insulin 131 2. Travel checklist 132 3. Travelling - sample letter 132 Chapter 19: Impaired Glucose Tolerance & Impaired Fasting Glycaemia 133 1. Impaired glucose tolerance and impaired fasting glycaemia 134 2. Patient information - impaired glucose tolerance and impaired fasting glycaemia 135 Useful Websites: For Patients And Healthcare Professionals 136 References 138 7 Guidelines for the Management of Diabetes 2005: Summary Aim of treatment: • To allow a full life; to control blood glucose, blood pressure and lipids; to prevent complications. Detection and initial action: • Screen: subjects with a family history of diabetes; Asian, Black Caribbean and Black African ethnic groups; subjects with other cardiovascular risk factors (e.g. hypertension); subjects with a history of gestational diabetes; and all those aged 45 years and over. • Patients with new type 1 diabetes need urgent referral to the hospital diabetes team. • Patients with type 2 diabetes who are unwell also require hospital referral for initial assessment. • Group education sessions are available at the Whittington Hospital for all patients in its catchment area with new type 2 diabetes, whether the patients are managed at the hospital clinic or in general practise (contact the Diabetes Specialist Nurses, Whittington Hospital - 020 7288 3344). Sessions are also run in the
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